Vested interest: I wrote to the new editor of the BJGP a few months ago asking if I could write about Atos, their disability ‘assessments’, and general practioners, but had an unenthusiastic response. I put this to one side, I hope, to discuss their shiny cover which is very yellow, and gives big font joy to say that “ACUPUNCTURE effective in a randomised controlled trial for patients with unexplained symptoms”. A quick google and several news outlets are taking this as fact.

I beg to differ.

80 adults were recruited with ‘unexplained symptoms’ (their term) ‘including fibromyalgia, headache and back pain’. (I don’t think these are ‘unexplained’, but anyway.) The patients had acupuncture, with a waiting list acting as a control group. Patients were asked to fill in a form ‘Measure Yourself Medical Outcome Profile’ at 26 weeks. Other surveys were asked of patients and medication use and GP consultation rates also measured at 26 and 52 weeks. The researchers say that

“The addition of up to 12 5-element acupuncture consultations to their usual care was feasible and acceptable and resulted in improved wellbeing and individualised (MYMOP) that was sustained at up to 12 months.”

First, we already know that acupuncture has similar outcomes to sham acupuncture: ie, it isn’t the ‘acupuncture’ that makes people feel better (if they do.) This fact wasn’t controlled for, which is, given current knowledge, a major problem. Second, the MYMOP scale improvements that were noted were small and fell over time in both the treatment and the waiting list group (it is worth noting that MYMOP is favoured by the British Flower and Vibrational Essences Association, as well as ‘integrated cancer care‘ centres.) This trend may be regression to the mean, things tending to get better over time, or it may be part of normal fluctuations, which the original paper on MYMOP showed happened to patients attending GPs. Third, there was a reduction in consultation rates with GPs in both control and intervention groups, but the rate remained higher in the intervention group than in the control group.

So what justifies the front page? I do not know. The authors would have us believe that “GPs may recommend a series of five-element acupuncture consultations as a safe and potentially effective intervention.” I think this is wrong in fact: I don’t see the evidence justifying this statement. I also think it that a recommendation like this is wrong because it misleads patients. There will be patients who will pay large sums for this intervention based on the headlines and who will not benefit from it.

There are many, genuinely holistic and evidence based interventions that can help people manage chronic and difficult conditions better. This isn’t one of them.

Update: DC has done a great piece on this paper, what is more, with graphs, which I am too inept to cut and paste here. Very very irritatingly I can’t link to the abstract or the text of this piece – neither seem to be on PubMed and the RCGP is behind a paywall. I have the paper journal beside me, which I am also too inept to scan in and make appear below. sorry.

let’s Euan – I have had renewed hope for the college post-Field with the wonderful Claire G in command – and I really don’t want the journal to let us down. How does one get to be a peer reviewer for them – I have done PR for other journals but never them – should there be more transparency about how peer reviewers are recruited ? I am in favour of making peer reviews open, for all to see, online and without anonymity for the writer. would be very happy to review for the BJGP – maybe we should offer ourselves. hm.

Just drafted summat – I’ll email it tonight to see what you think. Clare G is a great hope but the RCGP needs complete and utter root and branch reform. I feel for her as I think she has been completely sandbagged by these NHS reforms.

I think the BJGP has a policy of open peer review – but I think that means the authors get to see the peer reviewers’ names and there is no further disclosure. It would be helpful to get it all out in the open. I’d be happy to do it – I’m pretty sure I have registered at the site to do it in fact but I’ve never been asked! I may never be…

Being (only a bit?) snide, CAM topics have an expertise problem and a (related) bias problem. The reason is that most of the people who are routinely identified as “CAM experts” (i.e. who publish a lot on CAM interventions) have – in my opinion – a noticeable bias in favour of positive results, or at least in favour of equivocal results being made to sound positive. I suspect these are the same people authors of CAM stuff suggest as referees, or who mainstream journals – especially ones that are a bit lazy – identify as referees. It is, in effect, a kind of collective talking-up and back-scratching exercise.

Now, you can of course say this about other fields of biomedical research, but there it is checked, to varying degrees, by the existence of other people in the research area with different and competing views, who also referee stuff. This is not true in CAM as the CAM research community consists overwhelmingly of believers, or at least of sympathisers, see above.
Prof Edzard Ernst was a notable – and often rather lonely – exception, within CAM research, to all this kind of PC CAM-boosterism. But he is retiring.

Be afraid… be very afraid.

On a more positive note, you CAN find real critical analysis of studies on CAM. You just don’t find it in CAM (and even, as we see here, in mainstream) journals. The best place is blogs, including (one of the best single sources) the Science-Based Medicine blog written mostly by a collective of academic clinical people in the States. See, for instance, the piece mentioning the BrJGP paper from Yale neurologist Steve Novella.

This Academy was established over 40 years ago teaching doctors, nurses and physiotherapists Medical Acupuncture. (not to be confused with traditional Chinese acupuncture involving 5 elements, pulse diagnosis etc etc.
We now have several NHS hospitals GP practises useing this method with good results.
If there are any GPs with any doubts then I say, join our training course and prove it for yourselves.

http://www.ncbi.nlm.nih.gov/pubmed/16956145
“Systematic reviews of acupuncture have overstated effectiveness by including studies likely to be biased. They provide no robust evidence that acupuncture works for any indication.”http://www.bmj.com/content/338/bmj.a3115.full
for pain:
“A small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias.”
where’s the evidence?

A bit late in the day, and before noticing the August journal, with its hint of an apology for over egging the acupuncture paper, I sent in this letter. –

IF I COULD CANCEL MY SUBSCRIPTION I WOULD.

But I cannot without leaving the college.

Why does the journal wish to uncritically promote the meaningless hocus- pocus of alternative medicine? 1 It is bad enough that you published the paper, but to puff it up on the cover and in the Editor’s Briefing is unforgivable. Margaret McCartney2 has pointed to the hopelessness of the paper – no sham acupuncture group, trivial benefit using wierd rating scales. But why do I have to turn to her for a description of what the “five elements” are. Even in the extended on-line version this is not mentioned. They are fire, earth, metal, water and wood. How can any educated person read this and not laugh out loud? Publishing this paper encourages desperate patients to give their money to cruel charlatans and puts pressure on the NHS to fund nonsense.

And why are you hiding the criticism of the paper? Dr McCartney says that she has has written in online and surely others must have as well? The BMJ publishes all comments, even those very critical of the journal, within 24 hours. It would seem that at least you have the decency to be ashamed.